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VA National Center for Patient Safety

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TIPS Newsletter

TIPS is published quarterly (formerly bimonthly) and is the VA's official patient safety newsletter. It is meant to be a source of patient safety information for all VA employees and others who may face similar challenges within their patient care systems.

July/August/September 2017

April/May/June 2017

  • The Essential Role of Leadership in Developing a Patient Safety Culture: The Mountain Home VA Healthcare System's chief of quality management discusses The Joint Commission's Sentinel Event Alert, Issue 57 - The essential role of developing a safety culture and the various initiatives and programs available through the VA National Center for Patient Safety.
  • Joining Forces for Safer Care - Joint Patient Safety Reporting: The Department of Defense (DOD) and the Veterans Health Administration (VHA) collaborate on the Joint Patient Safety Reporting System (JPSR) - a standardized, simple way for safety-related incidents and issues to the appropriate patient safety professional.
  • Dedicated, Motivated, Safe and Sterile: The Central Alabama Veterans Healthcare System's (CAVHCS) Sterile Processing Service (SPS) is a dedicated team of professionals in the trenches of the patient safety improvement effort throughout the Veterans Health Administration (VHA).
  • Purchasing for Patient Safety: The Human Factors Engineering (HFE) section at the VA National Center for Patient Safety (NCPS) collaborates with stakeholders to ensure that products entering the VA supply chain are safe, reliable and efficient.
  • Passion for Patient Safety: A Doctor of Nursing Program (DNP) student fulfills her residency credits at the VA National Center for Patient Safety (NCPS).
  • Patient Safety Training - March 2017: A recap of the VA National Center for Patient Safety's (NCPS) recent Patient Safety Training Academy.
  • Putting a Face to a Name: Getting to know the patient safety managers in the Veterans Health Administration (VHA).
  • Tools to Reduce Perioperative Opioid-Related Risks: The VA National Center for Patient Safety (NCPS) Patient Safety Center of Inquiry at the Durham, NC VA Medical Center and colleagues discuss three tools for VA clinicians to help curb the nation's opioid epidemic.

January/February/March 2017

October/November/December 2016

  • NCPS Approach to Achieving High Reliability: NCPS Director Dr. Robin R. Hemphill and NCPS Director of Clinical Team Training Gary Sculli lay out a vision for VA to achieve High Reliability by creating a culture of safety throughout the Veterans Health Administration.
  • Pittsburgh's Center for Medical Product End-User Testing: Pittsburgh VA is the home to the Center for Medical Product End-User Testing (CMPET, an NCPS Patient Safety Center of Inquiry (PSCI). CMPET director Jamie Estock gives an update on the status and potential impact of the CMPET. 
  • The New Generation Risk Tool for VA HFMEA: PS team members Cassandra Zieminski and Stephen Kulju present the new HFMEA tool "Proactive Assessment for Safer Systems" or "PASS" which creates a digital workspace for completing HFMEAs in VA.
  • Great Catch - Magnetic Attraction: Louisville Robley Rex VAMC patient safety manager Crissy Knox and quality improvement specialist Kim Reibling highlight the 'good catch' of an MRI technician who had an interesting encounter with a Veteran.
  • NCPS Staffer Receives Prestigious Oliver Hansen Outreach Award: Recently retired NCPS staffer Linda Williams receives the Human Factors Ergonomics Society's (HFES) prestigious Oliver Hansen Outreach Award.
  • Chief Resident in Quality and Safety: An interview with Dr. Eric Yanke from the Madison VAMC who recently completed NCPS' Chief Resident in Quality and Patient Safety (CRQS) program and how it has helped him look at care from a systems perspective.
  • NCPS Patient Safety Boot Camp for Biomedical Engineers: NCPS biomedical engineer Katrina Jacobs discusses the BME boot camp and how it prepares newly hired BMEs to be a patient safety champion at their home facility.

Jul/August/September 2016

Contents include:
Pages 1-3. Good News About Access From Las Cruces, New Mexico
Pages 3-4. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA
Pages 5-7. Calling All Leaders: Paradigms for Embarking on the Just Culture Journey
Page 7. Putting a Face to a Name: Your Patient Safety Team
Pages 7-8. NCPS Offers a Just Culture Program

April/May/June 2016

Contents include:
Pages 1-4. A Road Map to Just Culture
Pages 5-6. Patient Medication Information Sheet Redesign Project
6. Putting a Face to a Name
Page 6. Remembering One of Our Own

January/February/March 2016

Contents include:
Pages 1-3. Making the Leap: The Story of How the VA NCPS Committed to Simulation as a Technique to Teach and Study Patient Safety
Page 3. Blueprint for Excellence" Focuses on High Reliability
Page 4. Human Factors as a Root Cause: Back to Blaming People?

July/August 2015

Pat Quigley and Julia Neily discussed VA’s fall reduction program at length in two podcasts that are available in the NCPS Falls Toolkit. The lead article in this issue of TIPS is meant to supplement the podcasts by offering the information in a print format, which can be used as a reference when developing a falls reduction program.

Pat Quigley is Associate Director, VISN 8 Patient Safety Center of Inquiry, and leads many of the center’s fall and injury reduction efforts. Julia Neily is Associate Director, VA NCPS Field Office, and has been involved in many quality improvement initiatives. 

  • Understanding the VA Fall Reduction Program: Falls reduction is a critical aspect of the VA patient safety program and a concern for caregivers around the nation. The key elements of VA’s efforts to reduce falls and injuries from falls are discussed.
  • Types of Falls and Suggestions to Reduce Them: Accidental falls, anticipated physiological falls and unanticipated physiological falls are defined. A number of efforts to protect patients from injury or to reduce severity are also discussed.

May/June 2015

  • High Reliability in the Operating Room: Targeting System Vulnerabilities: At the Birmingham VA Medical Center, an interdisciplinary team representing key areas of the operating room was formed to address a number of concerns with patient care that affect both VA and private sector hospitals.The article notes that three-quarters of the operating room staff felt substantial progress had been made because of the I-SLEEP initiative.
  • Safe Purchasing of Medical Devices: Purchasers of medical devices can have an effect on the safety of them by incorporating usability assessments as a part of their organization’s procurement process. As discussed in the article, the Nielsen and Shneiderman Heuristics tool can be used during the procurement process to reduce the likelihood of a device having design features that could put patients at risk.

March/April 2015

January/February 2015

November/December 2014

  • Surgery Risks are Higher for Obese Patients: Obese patients have a much higher risk of potentially fatal complications following surgery. Reducing risks for obese patients can also lessen the potential occurrence of adverse events or close calls.
  • Outreach: Providing a Framework for Patient Safety: Staff members of the VA New York Harbor Health System are helping sup­port the development of a patient safety program within the Medical Services Division of the United Nations.
  • Chief Residents in Quality and Safety "Boot Camp": Chief Residents in Quality and Safety jumpstart their journey into quality improvement and patient safety at a “boot camp,” which includes an introduction to simulation as a tool for practic­ing teamwork and communication skills.

September/October 2014  

  • Shreveport: A Success Story: At the Overton Brooks VA Medical Center, we have made a concerted effort over the past year to not just improve, but excel at being a safe and high-quality surgical service. As a result, we have made tremendous strides in changing the culture of our surgical service.
  • Managing Fatigue: In late 2011, the Joint Commission issued a Sentinel Event Alert on health care worker fatigue and patient safety. A substantial number of studies have indicated that extended work hours for health care workers contribute to high levels of worker fatigue, which can result in an increased risk of adverse events and reduced productivity.
  • Improving Communications at the Memphis VA Medical Center: The OR Improvement Committee was com­missioned in January 2013 and charged to improve first case starts and reduce turnover times in the operating room, which has been a success, using such things as standardized hand-off and communication templates.

July/August 2014

  • A Toolkit: Patients At Risk for Wandering:The article provides an overview of patients “at risk” for wandering, as well as a variety of interventions to prevent patients from wandering or missing from VA facilities and grounds.
  • Stop the Line for Patient Safety: An interdisciplinary team effort at the Robley Rex VA Medical Center, Louisville, Ky., has led to a successful and inclusive approach to the “Stop the Line for Patient Safety” initiative, launched by the VA in April 2013.
  • A “Great Catch” for Patient Safety: The Veteran’s Health Care System of the Ozarks began the successful “Great Catch” program in January 2013 to promote the reporting of close calls, a critical aspect of VA’s patient safety program.

 May/June 2014

  • Staff Leadership Key to Enhancing the Root Cause Analysis Process: Root cause analysis team leaders and teams organized at the Charles George VA Medical Center, Asheville, N.C., include a diverse group of staff members, in an effort to promote the idea that patient safety is everyone’s concern.
  • A “Lean” Way to Improve Patient Event Reporting: Michael E. DeBakey VA Medical Center, Houston, Texas, transitioned from a voluntary paper-only incident reporting process to an electronic patient event reporting system, known as “ePER,” July 1, 2013, which led to a 245 percent increase in reporting.
  • Improving Communications by “Training the Trainer”: Staff members from 25 areas at the VA Greater Los Angeles Healthcare System were selected as trainers and came together January 14-15, 2014 for a Clinical Team Training “train-the-trainer session,” designed to facilitate training opportunities and implementation of crew resource management-based projects system-wide.

March/April 2014

  • Going an Extra Mile for Patient Safety: The VA Greater Los Angeles Healthcare System Patient Safety Advisory Team goes the extra mile to coordinate the evaluation, reporting and follow-up actions that involve patient safety and adverse events, encouraging staff members at all levels of the system to participate.
  • Reducing Falls at the VA Boston Heathcare System: The VA Boston Healthcare System took a multidiscipliary approach to falls prevention that has resulted in a substantial reduction in the number of falls, following its participation in a virtual breakthrough series.
  • Teaming Up to Identify and Locate Absent or Missing Patients: In July 2013, the Birmingham VA Medical Center formed a team to complete their annual Healthcare Failure Mode Effect Analysis: identifying and searching for an absent or missing patient. The team successfully developed specific actions and outcome to meet a variety set of challenges.

January/February 2014

November/December 2013

  • Staying in Sync with High-Reliability Organizations: The VA’s patient safety program applies ideas from high-reliability industries, such as aviation, to target and eliminate system vulnerabilities, which is why NCPS staff members reviewed current industry practice at Delta Air Lines’ flight simulation center.
  • Working Together to Keep Veterans Safe: The VA Caribbean Healthcare System in San Juan, Puerto Rico, partici pated in a virtual breakthrough series with a goal of reducing 10% of fall events in acute care and 20% of fall injuries in long-term care.
  • The “Butler Tornados” Take on Falls Prevention: An interdisciplinary falls team who dubbed themselves “The Butler Tornadoes” were determined to reduce falls by 20% at VA Butler Healthcare’s “Village of Valor,” as a part of the virtual breakthrough series - but a 20% reduction turned out to be just the start.

September/October 2013

July/August 2013

  • Enterprise Risk Management: An Introduction: The overarching purpose of the Enterprise Risk Management process is to protect an organization from risks that could interfere with its objectives and goals and mitigate risk, where it is unavoidable.
  • A New Spin on Wheelchair Safety: The Pittsburgh H.J. Heinz Community Living Center developed a new approach to wheelchair safety, based on an innovative way to identify the chairs and purchase of higher quality seat cushions.

May/June 2013

March/April 2013

  • VISN 8 Improvement Forum: Sharing Good Ideas: The forum provided a unique opportunity for facility leaders to consider initiatives that might increase safety and efficiency at their medical centers.
  • Beyond insulin pen sharing: hospital systems issues: A 2013 Patient Safety Alert prohibited use of multi-dose pen injectors on all patient care units at VA medical centers, with specific exceptions. The article provides guidance on use of the pens per the exceptions noted in the Alert.

January/February 2013

November/December 2012

September/October 2012

July/August 2012

May/June 2012

March/April 2012

January/February 2012

  • National Patient Safety Goals, 2012: The Joint Commission has approved one new National Patient Safety Goal (NPSG) for 2012. The new goal, NPSG.07.06.01, is focused on catheter-associated urinary tract infections (CAUTI).
  • Preventing Fires in the OR: OR fires are rare, but can have serious and debilitating consequences. Fortunately, they occur in an extremely small percentage of the approximately 65 million surgical cases each year.
  • National Patient Safety Goals, 2012: The goals are presented in a summary format, to include which aspects of care each affects.

November/December 2011

September/October 2011

July/August 2011

May/June 2011

March/April 2011

January/February 2011

  • Joint Commission National Patient Safety Goals, 2011: The Joint Commission has made few changes to the National Patient Safety Goals that take effect January 2011, though some are planned for July 2011. This article highlights the changes and provides a poster concerning the goals and elements.
  • Preventing Wheelchair-Related Falls: An initiative developed by VAMC Martinsburg, W. Va., has reduced falls from wheelchairs at the facility’'s Community Living Centers.

November/December 2010

September/October 2010

July/August 2010

May/June 2010

  • The VA and Patient Safety: It has been just over 10 years since the Institute of Medicine published its landmark study on patient safety, To Err is Human. NCPS was also established in 1999. Veterans have a right to ask, “What has the VA accomplished?” This article answers that question.
  • Your VA Patient Safety Program at Work: Highlights of major NCPS programs and initiatives developed during the past 10 years.

January/February 2010

November/December 2009

  • Communicating Safety Through the VA's Electronic Health Record: This article discusses ways to improve communication among VA caregivers, which is increasingly dependent upon VA’s electronic health record, the Computerized Patient Record System.
  • Fighting Both the "Regular" and the New 2009 H1N1 Flu: Although "regular" or seasonal flu occurs throughout the fall, winter, and spring, the situation this year is extraordinary because of the H1N1 flu. This article summarizes the VA’s response.
  • Use of Color-Coded Wristbands: This article discusses why NCPS does not plan to pursue standardization of color-coded wristbands for events such as falls, do not resuscitate (DNR), or allergies.
  • Spotlight on Patient Safety and Recalls: Though patient safety alerts and advisories share a Web site with product recalls, members of each program have different duties and responsibilities, which this article discusses.

September/October 2009

  • A New Look at Aggregated Reviews: More than 5,000 Aggregated Root Cause Analysis reviews have been recorded in the NCPS Patient Safety Information System database. This article offers what has been learned during the initial efforts to categorize these aggregated reviews.
  • Evaluating a “Hand-Off Communication Checklist” Process: James A. Haley Veterans Hospital developed a hand-off checklist in 2005 and rolled it out in 2006. After three years of use, the patient safety staff felt it was time to review this document to see if its daily use was sustained or to edit it, if needed.
  • Summary of Root Cause Analyses Concerning Sleep Apnea: Sleep disorders have become an increasingly well-recognized health concern, underlined by the fact that the VA operates 85 sleep labs. A search of the NCPS Patient Safety Information System database found 12 root cause analyses associated with sleep apnea, which this article explores.

July/August 2009

May/June 2009

March/April 2009

  • Multiple-Dose vs. Single-Dose Drug Delivery Systems: This article discusses whether to stock multiple-dose or single-dose vials of a medication. Two issues are commonly evaluated: which option can reduce costs and which option can improve patient safety.
  • Delay in Outpatient Diagnosis and Care: Of 1,124 root cause analysis (RCAs) associated with delay of diagnosis and care, 18 percent were linked to outpatient care. A variety of actions were implemented by RCA teams to reduce or eliminate future occurrences.
  • Banning Tobacco Use in Acute Inpatient Psychiatric Units: Smoking bans on locked, acute inpatient psychiatric units are feasible in the Veterans Health Administration – and can offer many health and safety benefits to patients and staff.

January/February 2009

November/December 2008

September/October 2008

  • Improving the Safety of Anticoagulation Therapy: A VA anticoagulation work group has addressed anticoagulation therapy safety issues identified by IHI and the Joint Commission. Specific guidance on implementing these recommendations will appear in a VA directive.
  • Case Study: Biomedical Engineering: Human factors engineering problems became apparent when a pathologist noted abnormally high test results while working with certain test tubes.
  • News From the Patient Safety Reporting System (PSRS): An overview of PSRS is offered, to include contact information. PSRS is an external, confidential, voluntary, non-punitive reporting system that has been in use since 2001.

July/August 2008

May/June 2008

  • Making Falls Reduction a Full-Time Job: Having an advance practice nurse coordinate a facility'’s falls reduction program, combined with a facility'’s commitment to falls reduction, can lead to significant improvements.
  • VA’s Strategic Nap Program: Naps have been shown to dramatically increase alertness and performance in the laboratory and in field studies. This is true in health care and other high-risk settings. The program directly addresses the issue of what can be done about fatigue.

March/April 2008

January/February 2008

November/December 2007

September/October 2007

  • Medication Reconciliation: This article provides background information on this issue and suggestions on how to reduce related adverse medication events.
  • 2007 Patient Safety Initiative: The PSI is an opportunity for patient safety managers to apply for funding for creative patient safety projects. The article highlights successes during PSI 2006 and describes the proposals funded in 2007.

July/August 2007

May/June 2007

  • 2006 Patient Safety Initiative: The PSI is an opportunity for patient safety managers to apply for funding for creative patient safety projects. The article discusses this first PSI and describes the proposals funded.
  • How to Customize SBAR for Your Facility: Following a Medical Team Training session at the VA Northern Calif. Health Care System, the nurse executive team decided to implement SBAR and develop a related CPRS tool.
  • Teams Honored for Patient Safety Design Initiatives: Four teams were recognized for taking a creative approach to design during the VA National Patient Safety Managers Conference, March 2007.

March/April 2007

January/February 2007

  • JCAHO National Patient Safety Goals for 2007: Selected highlights of the new goals and new aspects of the pre-existing goals are provided. Pages 2 and 3 of this issue have been converted into a poster summarizing the application of the goals for easy reference.

November/December 2006

September/October 2006

July/August 2006

May/June 2006

  • Tablet Splitting: Table Splitting is a common practice often recommended by providers and implemented by healthcare systems. It has many benefits, and consideration of both drug and patient characteristics ensures safe and appropriate use.
  • New Directive: Preventing Retained Surgical Items in Surgical Procedures: During a surgical procedure, surgical teams employ standard “tools of the trade,” usually described in three categories: instruments, sharps, and sponges. Infrequently, one of these items can be accidentally left inside a patient after a surgical procedure is concluded.
  • Adverse Events Related to Do Not Resuscitate (DNR) Orders: DNR orders come with strong ethical implications. We would never want to withhold resuscitation when chosen to be attempted; nor conduct a code when DNR decisions have been conscientiously reached and agreed upon.

March/April 2006

  • Medical Team Training Program: The MTT program will be coming to VAMCs around the nation in the next few months. This article discusses the MTT process and highlights how the program has been succesfully begun at a number of facilities.
  • Beyond Preventive Maintenance: The article discusses how one facility reprogrammed IV pump medication menus by taking a team-based, systems approach to problem solving.
  • Using Caution with Fentanyl Patches: The use of fentanyl patches has changed the way pain medication is administered, but with convience come a number vunerablities, as this article shows.

January/February 2006

  • JCAHO National Patient Safety Goals for 2006: Selected highlights of the new goals and new aspects of the pre-existing goals are provided. Pages 2 and 3 of this issue have been converted into a poster summarizing the application of the goals for easy reference.

November/December 2005

September/October 2005

July/August 2005

  • Developing a Hands-On Museum: Starting a collection of devices to illustrate the good and the bad of human factors engineering can help RCA teams better conduct their duties and enhance a facility's patient safety program.
  • Improving Chemotherapy Safety: Introduction to the Patient Safety Center of Inquiry for Chemotherapy Safety: a summary of goals and activities.
  • A New, Simplified Approach to Medication Close Call Reporting: VAMC West Palm Beach has developed a user-friendly, computer-based format that has resulted not only in a significant increase in reporting, but in a better understanding of specific actions required to reduce adverse medication events.

May/June 2005

  • What Keeps You Awake at Night?: In 2003 and in 2004, NCPS conducted several day-long patient safety training sessions for VA facility leadership teams. This article concerns how these VHA leaders answered five specific questions that concern patient safety.
  • Read-Back – It’s Not Just for Nursing Units: The JCAHO patient safety goals that deal with high-risk communication haven't been implimented consistenly in diagnostic, patient care areas of hospitals, such as radiology and nuclear medicine.
  • Hand Hygiene and Diarrheal Diseases in Healthcare Settings: Although using an alcohol-based hand rub is usually the best way to routinely decontaminate hands, there are particular times when washing with soap and water and increasing the use of gloves are the best ways to prevent healthcare-associated infections.
  • Safety Spotlight: Telephone Triage Protocol: A discussion of the systems-based problems that developed when a patient called a facility's telephone triage line to complain of shortness of breath, tightness in his chest, and pain in the left shoulder.

March/April 2005

January/February 2005

November/December 2004

  • Medical Team Training — An Overview: Poor communication among clinicians is a leading source of adverse events in healthcare as evidenced by JCAHO goals related to communication. To address the need for improved communication, the VA developed Medical Team Training.
  • Safety on Inpatient Psychiatry Units — Always a New Challenge: It seems there are never enough eyes available to discover potential problems when working to ensure patient and staff safety on an inpatient psychiatry unit! This article discusses a specific incident and follow-on remedial actions.

September/October 2004

July/August 2004

May/June 2004

  • Introducing the Falls Toolkit: The kit is designed to provide comprehensive, practical, evidence-based resources for the prevention of falls and fall-related injuries, as well as provide advice for developing a falls prevention program.
  • Falls Resulting in Patient Injury or Death: Root cause analyses that involve falls, in which the patient experienced a fracture, another injury, or death, occur in a variety of locations and varied situations.
  • Preventing and Responding to Myiasis: Myiasis is a relatively rare occurrence in the United States and in U.S. healthcare facilities, but it does happen — even in hospitals without an obvious problem with cleanliness.

March/April 2004

December 2003

October/November 2003

August/September 2003

June/July 2003

December 2002

  • Special Edition: JCAHO Patient Safety Goals 2003:
    • Goal #1: Improve the Accuracy of Patient Identification
    • Goal #2: Improve the Effectiveness of Communication Among Caregivers
    • Goal #3: Improve the Safety of Using High-alert Medications
    • Goal #4: Eliminate Wrong-site, Wrong-patient and Wrong-procedure Surgery
    • Goal #5: Improve the Safety of Using Infusion Pumps
    • Goal #6: Improve the Effectiveness of Clinical Alarm Systems

July/August 2002

  • Could You Say That Again . . . It’s a Little LOUD in Here (excessive noise levels): Excessive noise levels associated with magnetic resonance imaging (MR) procedures have been known to be a problem for many years.
  • The Patient Safety Reporting System (PSRS) Safety Bulletins Coming Soon: PSRS, a NASA/VA collaboration independently operated by NASA to improve patient safety, has begun to receive patient safety reports from VA medical facilities at a rate that will allow the NASA PSRS office to issue de-identified findings.
  • MedWatch Reports: Information on the FDA’s safety information and adverse event reporting program, MedWatch.
  • View Point – Safety Hazards Around a Facility: The article discusses the importance of taking a second look at hazards around facilities, such as tree roots heaving the pavement (tripping hazards).
  • Sterilizing Medical Devices: On June 19, 2002, Advanced Sterilization Products issued a letter reminding its customers that all manufacturer instructions need to be followed when sterilizing and rinsing medical devices and products.
  • Safety Spotlight – Wrong ID Band: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • Ordering AEDs: VA facilities who order AEDs for their public facilities should be aware of the different types of AED models in the market.

May/June 2002

March/April 2002

  • Final Patient Safety Handbook Now on Web: On Jan. 30, 2002, the VHA National Patient Safety Improvement Handbook (VHA Handbook 1050.1) was officially adopted and the old 1051.1 rescinded.
  • Escorts Improving Patient Safety: Discusses development and implementation of an oxygen transport program with various components, including the Oxygen Patient Transport Communication Tool; escorts noted as an essential part of the team effort.
  • Safety Spotlight -- Patient Fall From Window: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • In Memoriam -- John Eisenberg, M.D., M.B.A: Thoughts on the death of John Eisenberg, M.D., M.B.A., after a lengthy illness. He was Director of the Agency for Healthcare Research and Quality.
  • Tips on Reducing Falls: During July 2001, 40 teams from VA and non-VA hospitals came together to begin a Collaborative Breakthrough Series on reducing falls and injuries in acute care and nursing home care settings. Collectively, the teams achieved a 45% reduction in serious injury rate over nine months.

January/February 2002

October/November 2001

July/August 2001

  • Psychiatric Ward Screens: Some older facilities still have windows in locked psychiatric wards fitted with security screens; problems discussed.
  • SPOT Update: Discusses capabilities of SPOT, an RCA software product, that replaced the Microsoft Word RCA template.
  • Oral Medication Syringes: Close call discussed involving a nurse drawing up an oral liquid medication.
  • VA Salt Lake City Develops Community Collaborative Partnership: Discusses the VA Salt Lake City Health Care System’s work with community agencies to promote patient safety initiatives throughout the state.
  • Safety Spotlight – Surgical Towels: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • RCA Team Tips: Helpful hints for those involved in the RCA process.

May/June 2001

March/April 2001

January/February 2001